Transcript PRESENTATION TITLE

IASP and the Classification of
Pain in ICD-11
Prof. Dr. Winfried Rief
University of Marburg, Germany
Disclosure Statement of conflict of interest in
the context of the subject of this presentation
Within the past 12 months, I or my spouse/partner have had
following financial interest/arrangement(s) or affiliation(s)
below.
Affiliation/Financial Relationship
•
•
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Support for travel
Honoraria for lectures
Honoraria for advisory board activities
Participation in clinical trials
Research funding
Financial shares and options
……………………………..
Company
Grunenthal
Berlin Chemie
Astra Zeneca, Heel
Astra Zeneca, Heel
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Socioeconomic Relevance:
Some Aspects
Pain is the major reason for health care use
Back pain is the most expensive condition in Western cultures
Pain as a disorder of its own: Major reason for worker‘s compensation
and premature retirement
Pain as a comorbid condition in cancer, diabetes, a.o. medical
conditions: turns long-term course into a costly condition for the society
and determines quality of life for affected patient
Providing adequate management for pain
patients:
Major problems
Pain is under-diagnosed all over the world
Several pain diagnoses are not feasible in medical care, especially for
GPs and other specialists
Pain management is not satisfactory in most countries
Financial coverage of pain management is unsatisfactory in many
countries
More efforts for pain research are needed
-> all these aspects depend on a proper classification of pain in
medical classification systems
The different facets of pain
Pain as a warning symptom
While treatment of the underlying medical condition is usually the primary focus, special
pain treatment can be additionally warranted (to reduce stress, to prevent learning and
memory mechanisms that can result in symptom persistence/chronification of pain, a.o.)
Pain as a disease of its own or a unique disease as a comorbidity of
other medical conditions
This is especially true for chronic pain conditions, where pain has no warning function. In
these cases, special pain treatment is always warranted.
Pain can be both a warning signal and a disease of its own
Again, in these cases special pain treatment is always required.
Examples: Diabetic Neuropathy
Classification systems must reflect treatment needs.
Current shortcomings of pain classification:
Some examples
Pain diagnoses are dispersed over various categories -> hard to find;
no clear rationale (sometimes organ-specific, sometimes rest categories
-> not feasible for other expert groups)
Pain diagnoses are in classification categories that are not relevant for
health care compensation / Diagnoses Related Groups DRG (e.g.,
under „General Symptoms and Signs“)
Some pain diagnoses need improved or updated classification criteria in
ICD-11, and proposals are available (e.g., fibromyalgia, low back pain,
IBS, headache)
Some pain diagnoses emphasize mind-body-dualism, although
biobehavioral models are more adequate (e.g., somatoform pain
disorder)
Specific examples for shortcomings:
Persistent somatoform pain disorder
The predominant complaint is of persistent, severe, and distressing
pain, which cannot be explained fully by a physiological process or a
physical disorder, and which occurs in association with emotional
conflict or psychosocial problems that are sufficient to allow the
conclusion that they are the main causative influences. The result is
usually a marked increase in support and attention, either personal or
medical. Pain presumed to be of psychogenic origin occurring during
the course of depressive disorders or schizophrenia should not be
included here.
(WHO, ICD-10, 2010 version)
Examples of Mechanisms of Symptom
Development and Maintenance
Humoral,
ANS,
Tissue
Brain /
CNS
Psychology
The American DSM-V approach:
Somatic Symptom Disorder
Criteria A, B, and C must all be fulfilled to make the diagnosis:
A. Somatic symptoms: One or more somatic symptoms that are distressing and/or
result in significant disruption in daily life.
B. Excessive thoughts, feelings, and behaviors related to these somatic symptoms
or associated health concerns: At least one of the following must be present.
(1) Disproportionae and persistent thoughts about the seriousness of one's symptoms.
(2) Persistently high level of anxiety about health or symptoms
(3) Excessive time and energy devoted to these symptoms or health concerns
C. Chronicity: Although any one symptom may not be continuously present, the state of
being symptomatic is persistent (typically >6 months).
Specifiers
Predominant Pain (previously pain disorder). This category is reserved for
individuals presenting predominantly with pain complaints who also asatisfy criteria B and
C of this diagnosis. Some patients with pain may better fit other psychiatric diagnoses
such as adjustment disorder or psychological factors affecting a medical condition.
Further Examples for the Need for Improved
Pain Classification: Cancer Pain
After cancer treatment, pain and fatigue are the major determinants of
disability, sickness leave, premature retirement etc.
Cancer pain has a strong tendency to persist (Rief et al., 2011, Breast Cancer
Res & Treatm)
Pain diagnoses and adequate pain treatment are crucial for cancer
patients to prevent disability and low role functioning.
The need to consider psychological features:
Will this patient develop persistent disabling low back pain?
Chou & Shekelle, JAMA 2010
Meta-Analysis, 20 studies, 10,800 patients
What predicts recovery one year later?
Low fear avoidance
Low impairment at baseline
What predicts persistence?
Non-organic signs
Maladaptive pain coping
High impairment
Psychiatric comorbidity
11
How to revise the pain diagnoses in the ICD-11
proposal?
Local improvements of criteria for pain diagnoses
(e.g., Chronic pain with psychological and somatic factors; F45.41 ICD10 GM)
Introduction of a new chapter or section on (chronic) pain
Potential parts of a new chapter in chronic pain
General Chronic Pain Conditions
x1 Chronic pain with somatic and psychological factors
x.2 Chronic pain, primarily psychological origin (former somatoform pain
disorder)
(Psychological factors that contribute to onset and/or maintenance of
disorder must be identified).
x.3 Chronic pain in the context of other medical conditions, but requiring
specific medical attention
x.31 Cancer Pain
x.32 Neuropathic Pain
Potential parts of a new chapter in chronic pain
Specific Pain Conditions
Y.1 Headache
Y.2 Back Pain/ Dorsopathy
Y.3 Fibromyalgia, chronic widespread pain
Y.4 Temporomandibular pain, atypical odontalgia
Y.5 Neck Pain, Whiplash Syndrome
Y.6 Chronic pelvic pain
Y.7 Chronic noncardiac chest pain
Y.8 Chronic joint pain (not head)
Y.9 Other Specific Chronic pain syndromes
Potential partners in a new chapter:
(Other) functional somatic conditions
V.1 Multiple Bodily Distress Disorder
V.2 Complex Irritable Bowel Syndrome (IBS with associated
psychological features)
V.3 Chronic Fatigue Syndrome, Neurasthenia
V.31 Chronic Fatigue in the context of Cancer
V.4 Environmental Sensitivity Syndromes
V.5 Health anxiety disorder
V.9 Other Bodily Distress Disorders
-> Overlap of symptoms, several psychological and biological
mechanisms
Summary
Adequate classification of pain is the basis for adequate treatment,
integration in health care systems, and focussed research programs
Tackling the economic consequences of pain requests adequate
classification
ICD-11 should be developed with the participation of pain experts /
IASP / EFIC
ICD-11 should consider new developments of pain research,
classification (e.g., headache), and treatment
Pain classification in ICD-11 must be also feasible for other specialists
(-> pain chapter?)
Thank you for your attention…
Reference:
Rief, W., Kaasa, S., Jensen, R., Perrot, S., Vlaeyen, J.W.S.
Treede, R.-D.,& Vissers, K.C.P.
New Proposals for the ICD-11 Revision of Pain Diagnoses.
Journal of Pain, 13, 305-316 (2012)